Muslim Clinic Data

Name of clinic/organization*
Email*
Phone
Website
Address
Street Address Address Line 2 City State ZIP Code
Year when clinic/organization began offering medical services
Total Number of Licensed Health Care Providers Actively Participating in Your Organization
We will ask a few questions about patient and staff numbers.
Total number of Medical Patient Visits: (A patient visit is a face-to-face meeting, online or in-person, between patient and health care professional in order to receive non-behavioral/dental medical services.)
Total number of Dental Patient Visits: (A patient visit is a face-to-face meeting between a patient and health care professional in order to receive dental services.)
Total number of Other Patient Visits: (A patient visit is a face-to-face meeting between a patient and health professional for non-medical/dental services, e.g., chiropractic, mental health counseling, social work)
Total Number of Licensed Health Care Provider Volunteer Hours: (If hours are documented.)
Total Dollar Value of Services offered by Licensed Health Care Providers: (You can determine this using any of the following ways: (1) An hourly rate based on state figures at Bureau of Labor Statistics--https://www.bls.gov/oes/current/oes_nat.htm; (2) Actual cost of services; or (3) Value based on number of visits or referrals.)
Total Dollar Value of Grants Received
Total Dollar Value of Donations: (Donations include items such as: monies, pharmaceuticals, eyeglasses, labs, x-rays, equipment, etc., but do not include grants.)
Total Number of Pre-Health Student Volunteers: (e.g. students in medical, dental, nursing, physical therapy, social work etc. training)
Total Dollar Value of Services Provided by Pre-Health Students
Total Number of General Staff Volunteers : (Volunteers performing general duties: answer the phone, medical records, make copies, repairs, etc.)
Total Number of General Staff Volunteer Hours
Total Dollar Value of Services for General Staff Volunteers
Total Dollar Value of Service
Is there anything else you would like to tell us?

Muslim Clinic Data

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